Stigma as a stressor and transition to schizophrenia after one year among young people at risk of psychosis

According to stress-vulnerability models, social stressors contribute to the onset of schizophrenia. Stigma and discrimination associated with mental illness may be a stressor for young people at risk of psychosis even prior to illness onset, but quantitative longitudinal data on this issue are lacking. We examined the cognitive appraisal of stigma-related stress as predictor of transition to schizophrenia among young people at risk of psychosis. In Zürich, Switzerland, 172 participants between 13 and 35years old and with either high or ultra-high risk of psychosis or risk of bipolar disorder were included. With 71 dropouts, transition was assessed during 12months among 101 participants of whom 13 converted to schizophrenia. At baseline, the cognitive appraisal of stigma as a stressor was measured by self-report, based on the primary appraisal of stigma as harmful and the secondary appraisal of resources to cope with stigma. Positive and negative symptoms were examined using the Positive and Negative Syndrome Scale. Compared with participants who did not convert to schizophrenia, converters had significantly more positive (p<.001) and negative (p<.001) symptoms and reported higher levels of stigma-related harm (p=.003) and stress (p=.009) at baseline. More perceived harm due to stigma at baseline predicted transition to schizophrenia (odds ratio 2.34, 95%-CI 1.19-4.60) after adjusting for age, gender, symptoms and functioning. Stigma stress may increase the risk of transition to schizophrenia. Research is needed on interventions that reduce public negative attitudes towards young people at risk and that support individuals at risk to cope with stigma-related stress.

[1]  M. Ruggeri,et al.  The role of experienced and anticipated discrimination in the lives of people with first-episode psychosis. , 2014, Psychiatric services.

[2]  K. Heekeren,et al.  Longitudinal course of self-labeling, stigma stress and well-being among young people at risk of psychosis , 2014, Schizophrenia Research.

[3]  Kristin A. Candan,et al.  Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial. , 2014, Journal of the American Academy of Child and Adolescent Psychiatry.

[4]  Linear equality restrictions in regression and loglinear models. , 1984 .

[5]  N. Rüsch,et al.  Emotional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness , 2014, European Archives of Psychiatry and Clinical Neuroscience.

[6]  E. Kuipers,et al.  Social networks and support in early psychosis: potential mechanisms , 2012, Epidemiology and Psychiatric Sciences.

[7]  P. McGuire,et al.  Comorbid Depressive and Anxiety Disorders in 509 Individuals With an At-Risk Mental State: Impact on Psychopathology and Transition to Psychosis , 2012, Schizophrenia bulletin.

[8]  Christoph Lauber,et al.  Social support modifies perceived stigmatization in the first years of mental illness: a longitudinal approach. , 2006, Social science & medicine.

[9]  S. Folkman,et al.  Stress, appraisal, and coping , 1974 .

[10]  P. Cuijpers,et al.  Preventing a first episode of psychosis: Meta-analysis of randomized controlled prevention trials of 12month and longer-term follow-ups , 2013, Schizophrenia Research.

[11]  J. Klosterkötter,et al.  WC1C DEVELOPMENT AND EVALUATION OF THE SCHIZOPHRENIA PRONENESS INSTRUMENT, ADULT VERSION (SPI-A) , 2006, Schizophrenia Research.

[12]  D. Sheehan,et al.  The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. , 1998, The Journal of clinical psychiatry.

[13]  Tyrone D. Cannon,et al.  Coping styles of individuals at clinical high risk for developing psychosis , 2014, Early intervention in psychiatry.

[14]  K. Heekeren,et al.  Early Recognition of High Risk of Bipolar Disorder and Psychosis: An Overview of the ZInEP “Early Recognition” Study , 2014, Front. Public Health.

[15]  K. Heekeren,et al.  Well-being among persons at risk of psychosis: the role of self-labeling, shame, and stigma stress. , 2014, Psychiatric services.

[16]  Eric V. Strobl,et al.  Predicting the risk of psychosis onset: advances and prospects , 2012, Early intervention in psychiatry.

[17]  T. Hergueta,et al.  The mini international neuropsychiatric interview , 1998, European Psychiatry.

[18]  S. Kay,et al.  The positive and negative syndrome scale (PANSS) for schizophrenia. , 1987, Schizophrenia bulletin.

[19]  C. Corcoran,et al.  Public stigma associated with psychosis risk syndrome in a college population: implications for peer intervention. , 2013, Psychiatric services.

[20]  W. Kawohl,et al.  Efficacy of Coming Out Proud to reduce stigma's impact among people with mental illness: pilot randomised controlled trial , 2014, British Journal of Psychiatry.

[21]  P. McGuire,et al.  Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. , 2012, Archives of general psychiatry.

[22]  A. Malla,et al.  A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants , 2010, Psychological Medicine.

[23]  Patrick W. Corrigan,et al.  A stress-coping model of mental illness stigma: II. Emotional stress responses, coping behavior and outcome , 2009, Schizophrenia Research.

[24]  C. Morgan,et al.  Social networks, support and early psychosis: a systematic review , 2012, Epidemiology and Psychiatric Sciences.

[25]  A. Yung,et al.  Social environmental risk factors for transition to psychosis in an Ultra-High Risk population , 2015, Schizophrenia Research.

[26]  Norman Sartorius,et al.  Global Pattern of Experienced and Anticipated Discrimination against People with Schizophrenia: a Cross-sectional Survey , 2009 .

[27]  P. Mcguire,et al.  Negative psychotic symptoms and impaired role functioning predict transition outcomes in the at-risk mental state: a latent class cluster analysis study , 2013, Psychological Medicine.

[28]  L. Ellman,et al.  Racial discrimination is associated with distressing subthreshold positive psychotic symptoms among US urban ethnic minority young adults , 2014, Social Psychiatry and Psychiatric Epidemiology.

[29]  A. Gamma,et al.  The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. , 2005, Journal of affective disorders.

[30]  Patrick W. Corrigan,et al.  A stress-coping model of mental illness stigma: I. Predictors of cognitive stress appraisal , 2009, Schizophrenia Research.

[31]  C. Correll,et al.  Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions , 2013, World psychiatry : official journal of the World Psychiatric Association.

[32]  R. Murray,et al.  Migration, ethnicity, and psychosis: toward a sociodevelopmental model. , 2010, Schizophrenia bulletin.

[33]  T. McGlashan,et al.  Risk factors for psychosis: impaired social and role functioning. , 2012, Schizophrenia bulletin.

[34]  D. Malaspina,et al.  Temporal association of stress sensitivity and symptoms in individuals at clinical high risk for psychosis , 2012, Psychological Medicine.

[35]  Godfrey D Pearlson,et al.  Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. , 2003, Schizophrenia bulletin.

[36]  F. Schultze-Lutter,et al.  Differences in coping, self-efficacy, and external control beliefs between patients at-risk for psychosis and patients with first-episode psychosis , 2014, Psychiatry Research.

[37]  Hok Pan Yuen,et al.  Long-term follow-up of a group at ultra high risk ("prodromal") for psychosis: the PACE 400 study. , 2013, JAMA psychiatry.

[38]  R. Bentall,et al.  The Impact of Social Deprivation on Paranoia, Hallucinations, Mania and Depression: The Role of Discrimination Social Support, Stress and Trust , 2014, PloS one.

[39]  Katherine E Henson,et al.  Risk of Suicide After Cancer Diagnosis in England , 2018, JAMA psychiatry.

[40]  E. Cantor-Graae,et al.  Hypothesis: social defeat is a risk factor for schizophrenia? , 2007, The British journal of psychiatry. Supplement.

[41]  P. Michaels,et al.  Diminishing the self-stigma of mental illness by coming out proud , 2015, Psychiatry Research.

[42]  H. Möller,et al.  Coping as a predictor of treatment outcome in people at clinical high risk of psychosis , 2016, Early intervention in psychiatry.

[43]  D. Penn,et al.  Recognizing and responding to early psychosis: a qualitative analysis of individual narratives. , 2008, Psychiatric services.

[44]  George Mendelson,et al.  Book Reviews , 1995 .

[45]  B. Major,et al.  The social psychology of stigma. , 2005, Annual review of psychology.

[46]  Tyrone D. Cannon,et al.  Cortisol Levels and Risk for Psychosis: Initial Findings from the North American Prodrome Longitudinal Study , 2013, Biological Psychiatry.

[47]  M. Pruessner,et al.  Stress and protective factors in individuals at ultra-high risk for psychosis, first episode psychosis and healthy controls , 2011, Schizophrenia Research.

[48]  Lawrence H. Yang,et al.  Perceived discrimination and psychotic experiences across multiple ethnic groups in the United States , 2014, Schizophrenia Research.

[49]  Andreas Meyer-Lindenberg,et al.  Neural mechanisms of social risk for psychiatric disorders , 2012, Nature Neuroscience.

[50]  Nicolas Rüsch,et al.  Challenging the public stigma of mental illness: a meta-analysis of outcome studies. , 2012, Psychiatric services.

[51]  Tyrone D. Cannon,et al.  Perceived discrimination in those at clinical high risk for psychosis , 2014, Early intervention in psychiatry.